IOSR Journal of Dental and Medical Sciences (IOSR-JDMS)

e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 14, Issue 9 Ver. I (Sep. 2015), PP 97-100
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Prevalence of Labial Frenum Attachment and its Relation to

Diastemia and Black Hole in Kurdish Young Population
Dler A. Khursheed1*, Shamal S. Zorab1, Faraedon M. Zardawi1, Azheen J. Ali2,
Ranjdar M. Talabani3
1

(Department of Periodontics, School of Dentistry/ University of Sulaimani, Iraq)

(Department of Orthodontics, School of Dentistry/ University of Sulaimani, Iraq)
3
(Department of Conservative, School of Dentistry/ University of Sulaimani, Iraq)
2

Abstract:
Introduction: Frenum appears as a fold of mucous membrane extending from the mucous lining of the labial
mucous membrane towards the crest of the residual ridge on the labial surface. Labial frenum is a dynamic and
often unstable structure and it will be changed in shape, size, and position during the different stages of growth
and development. Midline diastemia is a distinctive space usually of about 0.5 mm between mesial surfaces of
two teeth. It is more frequently seen between upper maxillary incisors causing esthetic and phonetic problems
Aims and Objectives: To determine the prevalence of high frenal attachment and maxillary median diastemia in
Sulaimani population.
Materials and Methods: This cross sectional study was conducted on 279 patients (132 male and 147 female)
who visited Oral Diagnosis Department of School of Dentistry University of Sulaimani for different purposes of
dental treatments. The ages of the patients were divided into two groups (10 to 20) and (20-30) years.
Examination was done on the dental chair;the frenum morphology was determined by using the direct visual
method under dental unit light.
Results: The results showed that about 68.8% of the patients had gingival frenal attachment, followed by
papillary 16.5, mucosal 12.5 and least frequent papillary penetrating 2% respectively. Of 279 patients, 239 of
them had complete maxillary midline closure, 25 of them had diastemia and 15 recorded black hole.
Conclusion: This study found that gingival frenal attachment constituted the higher percentage among all
frenal attachment in all age and sex groups. Complete contact between maxillary central incisors comprisedthe
higher percentage followed by diastemia and black hole.
Keywords: Frenum, Diastemia, Black Hole

I. Introduction
Frenum is a fold of mucous membrane consisting of highly vascularized connective tissue covered with
epithelium. It contains a variable amount of collagenous fibrous tissue1. This fibrous tissue attaches the lip to the
alveolar mucosa and underlying periostium 2. A normal frenum attaches apically to the free gingival margin so as
not to exert a pull on the zone of the attached gingiva and usually terminating at the mucogingival junction.
However, its level may vary from the height of vestibule to the crest of the alveolar ridge and even to the incisal
papilla area in the anterior maxilla 3. Labial frenum is a dynamic and often changeable structure and itgoes
through variation in shape, size, and position during the different stages of growth and development. During
growth, it tends to decrease in size and lose clinical importance. In young children, the frenum is generally wide
and thick, and during growth it becomes thin and small4.Their primary function of labial freniiis to provide
stability of the upper and lower lips5.
Midline diastemia is a distinctive space usually of about 0.5 mm between mesial surfaces of two central
teeth6.It is more frequently seen between upper maxillary central incisors causing esthetic and phonetic
problems7. Genetic, dentoalveolar disproportion, missing tooth, peg shaped lateral incisors, unerupted midline
supernumerary teeth, proclination of the upper labial segment or increased anterior overbite are considered as
primary etiologic factors for this structural phenomenon. Furthermore, rotated teeth, parafunctional oral habits,
such as thumb/finger sucking or abnormal tongue posture, orthodontic treatment, as in cases of rapid palatal
expansion or false teeth movement, pathologic teeth migration due to periodontal disease and prominent labial
frenum may regard as key etiologic factors for producing maxillary midline diastemia8,9.
Distribution of different types of high frenal attachment and interdental spaces between maxillary
central incisors in Sulaimani population has not been studied widely. Therefore, the purpose of this study,
therefore, is to determine the prevalence of high frenal attachment and maxillary median diastemia in Sulaimani
population.

DOI: 10.9790/0853-149197100

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Prevalence of Labial Frenum Attachment and its Relation to Diastemia and Black Hole in Kurdish
II. Materials And Methods
This cross sectional study was conducted on 279 patients (132 male and 147 female) who visited Oral
Diagnosis Department of School of Dentistry University of Sulaimani for different purposes of dental
treatments. Patients were implicated into two age groups a younger age group (10 to 20) and an older age
group - (20-30) years.Ethical approval was obtained from the University Research Ethics Committee, School of
Dentistry University of Sulaimaniwhich is in accordance with Helsinki Declaration.
The study started from November 2014 to May 2015. Exclusion criteria included Patients with
systemic diseases suffering from periodontitis and patients whose labial frenum and adjacent mucosa was
affected by trauma, moreover, patients taking medicine affecting gingiva, patients with orofacial defects and
whose frenum had undergone surgery were also excluded from this study.
Examination was done on the dental chair;the frenum morphology was determined by applying direct
visual method under dental unit light. Patients lip was gently stretched in horizontal direction away from labial
alveolar process to maintain frenum consistency. The interproximal spaces between maxillary central incisors
were examined for the presence of complete closure, diastemia and black hole. All examinations were carried
out by an expert periodontistafter taking verbal consent. Maxillary labial frenum were classified into four types
according to Placek (1974)8 classification given by mucosal, gingival, papillary and papillary penetrating.
Statistical Analysis: Data analysis was carried out using statistical packages, namely SPSS version
19.0. Statistical significance association between type of frenum, diastema and black hole with different
variables are studied using Chi square test. P-value less than 0.05 is considered as statistically significant, at
corresponding Degrees of freedom (df).
III.
Results
The results showed that about 68.8% of the patients had gingival frenal attachment, followed by
papillary 16.5%, mucosal 12.5% and least frequent papillary penetrating 2% respectivelyFig.1. The younger age
group showed lower percentage of mucosal frenal type than older age group (13:22) however, the gingival,
papillary and papillary penetrating types were higher in younger age than the older age group (104:88, 31:15
and 5:1) respectivelyTable 1.There was a significant relation between frenal attachments and age (P0.05).
Regarding comparison of frenal attachment types with sex, female showed higher mucosal and papillary and
papillary penetrating (21:14, 31:15 and 4:2) frenal attachments respectively while male recorded higher gingival
frenal typeTable 2. Statistical analysis found non-significant relation between sex differences and frenal
attachments.
Of 279 patients, 239 of them had complete maxillary midline closure, 25 of them had diastemia and 15
recorded black holeFig.2. According to age factor, diastemia and black hole recorded higher percentages in
younger age groups (17:8 and 8:7) respectivelyTable 3. Non-significant relation was seen between age groups
and diastemia was found. Regarding the relation of sex differences, female showed higher number of patients
with diastemia (16:9), while male recorded higher number of black hole (9:6)Table 4. Data analysis also
detected non-significant relation between sex predilection and diastemia.
IV.
Discussion
Frenum appears as a fold of mucous membrane extending from the mucous lining of the labial mucous
membrane towards the crest of the residual ridge on the labial surface10or to the incisal papilla area in the
anterior maxilla3. The characterization of the maxillary labial frenum and the interdental spaces of maxillary
central incisors are important because they may impose some modifications in dental treatment procedures.
The currentstudy is across-section study performedon 279 patients that attended Diagnosis Department
of School of Dentistry at University of Sulaimani to characterize the distribution of different types of maxillary
labial frenal attachments. The most common type of frenal attachment that observed in this study was gingival
type while the least common type was papillary penetrating. Similar results wasachieved by Upadhyay and
Ghimire among Nepalese children in 201211. Another study also recorded high percentage (58.2%) of gingival
frenal type among 428 Italian children12.
The adolescent group (10-19) showed higher percentages of gingival, papillary and papillary
penetrating gingival attachment in contrary young adults (20-30) recorded higher percentage of mucosal type in
our study. Comparing to Upadhyay and Ghimire, they found that mucosal and gingival attachment was higher in
older age group (8-14 years) whereas papillary and papillary penetrating was higher in younger age group of
children (1-7 years)11.The current study results disagree with the Jaczuk and Banach study that found higher
prevalence of mucosal attachment (39%) followed by gingival type (36%) among 1542 polish teen13.These data
indicate that the papillary and papillary penetrating type may decrease with increasing age. This study also
detected higher percentages of gingival type among males whereas females showed higher percentages of the
other three types of frenal attachments.
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Prevalence of Labial Frenum Attachment and its Relation to Diastemia and Black Hole in Kurdish
Regarding maxillary interdental spaces, there were high percentage of complete interdental closure
between maxillary central incisors, diastemia followed by (8.96%) then the black hole by (5.38%). Umanah et al
found higher percentage of diestemia among selected Nigerian young adult population 62.4%3. Another study in
Saudi Arabiareported high prevalence 64.6% of diastemia among 6-year-old children but only 14.3% amon 12year-olds14, This is rather consistent to the results of the current study. Furthermore, the current study reported a
higher prevalence of maxillary median diastemia in females (5.73%) than males (3.23%) and higher black hole
in males (3.23%) than females (2.15%). In contrary the same study in Saudi Arabia found higher percentage of
diastemia in males (25%) than females (14%)14.This is conversely higher than our results.
It is acknowledged that the prominent of the maxillary labial frenum may diminish with age
simultaneously with approximating proximal surfaces of maxillary incisors. Therefore, the clinician should
evaluate maxillary labial frenum and maxillary median diastemia before establishing any dental procedure, as
some of these problems may disappear gradually with age and some other may require surgical interventions.

V.
Conclusions
The current study has found that the majority of frenal attachments was gingival type. The next more prevalent
types were papillary and mucosal and lest frequent was papillary penetrating. Complete interdental closure
constituted the majority of the interproximal relation of the maxillary central incisors. There were less frequent
interproximal gaps and black holes among attendee patients.
References
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Popovich, F., G. W. Thompson, and P. A. Main. "The maxillary interincisaldiastema and its relationship to the superior labial
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Ambalavanan, N., Pamela Emmadi, M. Priyanka, T. Ramakrishnan, and R. Sruthi. "An overview of frenal attachments." Journal of
Indian Society of Periodontology 17, no. 1 (2013): 12-15.
Mohan, Ranjana, Pankaj Kumar Soni, MunagalaKarthik Krishna, and Mohan Gundappa. "Proposed classification of medial
maxillary labial frenum based on morphology." Dental Hypotheses 5, no. 1 (2014): 16.
Nagaveni, N. B., and K. V. Umashankara. "Morphology of maxillary labial frenum in primary, mixed, and permanent dentition of
Indian children." Journal of Cranio-Maxillary Diseases 3, no. 1 (2014): 5.
Mirko, Placek, SkachMiroslav, and MrklasLubor. "Significance of the labial frenum attachment in periodontal disease in man. Part
I. Classification and epidemiology of the labial frenum attachment." Journal of periodontology 45 (1975): 891-4.
Nangia, Tanu, GulsheenKaurKochhar, and ShardaYadav. "Midline Diastema: Crossroad of Treatment Planning."
Govila, Vivek; Govila, Smita .Cosmetic Creations - Through Diastema Closure.Indian Journal of Dental Sciences.3 no. 4(2012) 7477.
Umanah, Ayama, Abdul-AzeezOmogbai, and BabatopeOsagbemiro. "Prevalence of artificially created maxillary midline diastema
and its complications in a selected nigerian population." African health sciences 15, no. 1 (2015): 226-232.
Gkantidis, Nikolaos, Olga-ElpisKolokitha, and NikolaosTopouzelis. "Management of maxillary midline diastema with emphasis on
etiology." Journal of Clinical Pediatric Dentistry 32, no. 4 (2008): 265-272.
Zarb, George A., JohnHobkirk, Steven Eckert, and Rhonda Jacob.Prosthodontic treatment for edentulous patients: complete
dentures and implant-supported prostheses. Elsevier Health Sciences, 2013.
Upadhyay, Sumita, and Neeta Ghimire. "Attachment of Maxillary Labial Frenum in Nepalese Children." Orthodontic Journal of
Nepal 2, no. 1 (2013): 38-31.
Bergese, F. "[Research on the development of the labial frenum in children of age 9-12]." Minerva stomatologica 15, no. 10 (1966):
672-676.
Jaczuk, Zbigniew, and Jadwiga Banach. "Prevalence of narrow zone of attached gingiva and improper attachment of labial frena in
youths." Community dentistry and oral epidemiology 8, no. 7 (1980): 385-386.
Luqman, Master, Syed Sadatullah, Mohammad YunisSaleem, Mohammed Ajmal, YahyaKariri, and MushababJhair. "The
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VI.

Tables and Figures:

6

46

35

Mucosal
Gingival

192

Papillary

Figure 1: Prevalence of frenal attachment types among dental patients.

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Prevalence of Labial Frenum Attachment and its Relation to Diastemia and Black Hole in Kurdish

25

15

Complete
closure
239

Figure 2: prevalence of maxillary midline diastemia among dental patients.

Table 1: Relation betweenage groups and frenal attachment types.
Age

10-19
20-30
Total

Mucosal

Gingival

Frenum
Papillary

13
(4.66%)
22
(7.89%)
35
(12.55%)

104
(37.28%)
88
(31.54%)
192
(68.82%)

31
(11.11%)
15
(5.37%)
46
(16.48)

Papillary
penetrating
5
(1.79%)
1
(0.36%)
6
(2.15%)

Chi square

P-value

X2=9.354

P=0.0249
Significant
(p<0.05)

Table 2: Relations betweebsex groups and frenal attachment types.

Sex

Mucosal

Gingiva

Frenum
Papillary

Male

14
(5.02%)
21
(7.53%)
35
(12.55%)

101
(36.2%)
91
(32.62%)
192
(68.82%)

15
(5.37%)
31
(11.11%)
46
(16.48)

Female
Total

Papillary
penetrating
2
0.72%)
4
(1.43%)
6
(2.15%)

Chi square

P-value

X2=7.368

P=0.0611
N.S
(p>0.05)

Table 3: Relation between age groups and diastemia.

Age
10-19

Complete
closure
128 (45.88%)

20-30

111 (39.78%)

Total

239 (85.66%)

Diastemia

Black hole

Chi square

P-value

17
(6.09%)
8
(2.87%)
25
(8.96%)

8
(2.87%)
7
(2.51%)
15
(5.38%)

X2=1.921

P=0.3827
N.S*
(p>0.05)

Table 4: Relation between different sex groups and diastemia.

Gender
Male
Female
Total

Complete
closure
114
(40.86%)
125
(44.8%)
239
(85.66%)

DOI: 10.9790/0853-149197100

Diastemia

Black hole

Chi square

P-value

9
(3.23%)
16
(5.73%)
25
(8.96%)

9
(3.23%)
6
(2.15%)
15
(5.38%)

X2=2.266

P=0.3220
N.S
(p>0.05)

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